The thin (disappearing?) line
I'm sure you're all anxiously awaiting the new edition of the Diagnostic and Statistical Manual of Mental Disorders V (also known as DSM V, replacing DSM IV). You should be. In now-outdated edition IV there apparently was a footnote of sorts that made grief an exclusion to depression. In the draft edition of V however, the footnote is removed, and grief is essentially enveloped into the definition of depression. Which means, you, me, anyone who experiences a loss that s/he mourns (well, mourns deeply for more than say two weeks), will be thusly classified as suffering from depression. (To reiterate, right now V is in draft stage. The following discussion is on a possible -- but significant -- change in psychiatric diagnosis.)
If you've ever been hit up in a doctor's office by the quicky depression Q&A, you know it asks such things as, Do you have trouble sleeping? Do you have trouble focussing and making decisions? Has your appetite changed recently? And if you check yes to a certain number of these, you go on the doc's radar as being depressed. But if you're grieving the death of your child(ren), many of us probably answer yes to these questions, too. Have you lost joy? Does it take a great effort to do small things? Do you ever think about killing yourself?
So how to tell the difference between grief and depression? Is there a difference or is this a matter of semantics? Does it help or hurt our case when we say things like, "You never really get over it, you get through it and learn to live with it"?
There's an NPR news article on this shift in classification here. According to this article, there is in fact a difference between bereavement and depression, but according to the doctor quoted therein it seems to be one of time: weeks. Not months, but weeks. If you're not rethinking some of those questions above in the space of 14-21 days, you will now be hit with a diagnosis of depression.
Huh.
Allen Frances has emerged as one of the lead critics against this particular change. Frances was the chairman of the group who devised DSM IV, and wrote an op-ed in the New York Times highlighting his concerns. (Op-ed can be found here; sign in may be required.) Among Frances' problems with the proposed change from IV to V are that healthy people who happen to be hit upside the head with a loss will now be labeled as depressed. Which is a problem if you're applying for health care or a job. Frances also worries that drugs will now be willy-nilly doled out to people in mourning, who either won't need them, or will unnecessarily remain on them. Frances writes,
Turning bereavement into major depression would substitute a shallow, Johnny-come-lately medical ritual for the sacred mourning rites that have survived for millenniums. To slap on a diagnosis and prescribe a pill would be to reduce the dignity of the life lost and the broken heart left behind. Psychiatry should instead tread lightly and only when it is on solid footing.
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I used anti-depressants, but they were not foisted on me by a doctor in the hospital. They also came later than two-three weeks. On the contrary, I went about a month or six weeks until it hit me one day that I was no longer functioning in a capacity that I needed to for the safety and well-being of my two-and-a-half year old. (I wrote about my decision to use anti-depressants here on Glow; the post can be found here.) I was also in the care of a psychoanalyst, and the decision to go on medication was entirely mine -- as was the decision to go off them in six months. They did not take away my pain or mitigate my grief. They did not put me in a fog, or even make me feel better. They helped me function. I still felt the awful full force, but could now drive and lift myself out of bed and otherwise make sure my toddler didn't play with knives while I hid under the covers.
Perhaps I'm different in that I actually sought help, and I'm wondering if there are babyloss parents out there who should but are caught in that whole "Can't make decisions" and "Small things are difficult" mode and don't pick up the phone to make that appointment. Or maybe I'm the rarity of which Frances speaks who actually needed treatment.
I'm a bit confused about the change from IV to V because it seems that there are already clear markers in place in order to make this distinction, markers that medical professionals are quite comfortable with. When I interviewed a grief counsellor for this site (interview found here) I asked her point blank what the difference was between grief and depression, and she gave a long and nuanced answer involving "normal" and "complicated" mourning, and the ability to "bracket" one's feelings later in the process and keep them somewhat separate from other parts of their lives. She also pointed out that it takes much longer than a few weeks to process loss and go through some of the more severe feelings. It seems to me this makes an enormous amount of sense. Are the people writing version V worried that psychoanalysts won't be able to do their jobs properly and discern these gradations? (Hey wait, aren't psychoanalysts doing the re-writing? Are they saying this is too difficult a job, or they can't be bothered, or what?)
Although I agreed almost entirely with Frances' arguments, I bristled a bit at " the sacred mourning rites that have survived for millenniums." Because I think babyloss is it's own little dark corner of bereavement, and I think we show here and on our blogs on a weekly basis that contemporary society has a ways to go before it wholesale accepts our particular grief as a healthy if not painful and uncomfortable process that people experience. Babyloss parents frequently speak of having no one to turn to or talk to, and in fact, document people turning and running in the other direction when given their news. God bless the internet, because places like this -- here, online -- have become a life-line for many who need to grieve and make sure they're in some bounds of normalcy. As we all showed a month or so ago when I asked for input on funeral services, there aren't as much "rites" as there is "getting through the moment to the best of our abilities." So where does this put us on the analytic scale? Are we difficult to place? So difficult that we might as well just lump us in the larger definition of depressed? I'm not saying because we as a group lack a cohesive and common social experience ergo we need Zoloft; perhaps this is a clarion call to examine babyloss more closely and for society to agree to abide and sympathize with us and give us the support that we so desperately need.
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I want to open this to discussion to the people whom it actually affects. You. And find out what you think.
But.
I don't mind anyone here getting defensive about being labeled depressed right out of the gate. Hell, I'm a bit pissed about it all, too. But I think we need to be a bit careful that our arguments against Draft DSM V's line of thinking don't play into any preconceived negative notions of depression, therapy, and anti-depressants. Society may not know how to deal with babyloss parents, but let's face it -- we're also battling a stigma of depression that paints its sufferers as weak. Weak and perhaps suicidal, delusional, or even alcoholic depending on what Lifetime movie you've seen recently. And there are people here, who read here, who have sought out therapy and used anti-depressants to their advantage, who have crossed that line between mourning and depression. Let's not take them down, too.
And what I'd really regret is slamming the new proposed change and taking down anti-depressants with it and then leaving a newly bereaved parent saying, "Well hell, I'm just grieving goddammit." And not wanting to eat his or her words two months later when they get knocked to the ground and are scraping the barrel because sometimes it's hard to make a decision, and sometimes its really hard to make a decision where you have to admit you were wrong about something, publicly. It shouldn't be that tough to ask for help, and to get it.
If I've learned nothing else writing and reading around here over the past few years, it's that everyone grieves differently. So I ask that in the comments, we're mindful of this.
So let's hear it. How do you feel about the proposed change that will essentially make grief a mental disorder? Semantics? Do you see a problem that could impact your life directly? Do you feel funny being labeled as such, or relieved that someone is even paying attention? Do you think you ever crossed that line between grief and depression, or think that you could? If you could address the people drafting DSM V, what would you tell them that you think might be helpful in making their decision? I realize many of you have already addressed this issue on your blogs -- please post a link to any posts in the comments.
25 Comments
Reader Comments (25)
I do think the line between grief and depression is very thin. I walk it everyday. There are those days and even weeks when getting up, getting dressed and eating are almost beyond my ability. I do worry about over prescribing drugs; hell I think there is already too much of that in this day and age.
But we shouldn't deny those who need help because their type of grieving isn't severe enough. Pregnancy and infant loss are particularly long term grieving processes that can't be contained to 14-21 days.
I am in favor of there being a diagnosis of complicated grief - grief compounded by trauma, compounded by depression, compounded by the difficult manner of loss, or by pre-existing conditions in the grieving person's life. I do want people who need help to be able to get help and to have it covered by health insurance.
Should babyloss automatically be categorized as complicated grief? I don't think so. It's so very individual how we each respond to it. My grief certainly was/is complicated. I was diagnosed with post-traumatic anxiety, which I treated with counseling and acupuncture. But I really considered medication, and if I had needed it, I would have wanted it covered. But it's not necessarily like that for everyone.
With that said, I don't think grief should be subsumed under the category of depression. It just strikes me as so disrespectful to this deeply normal, human process. If I could give my two cents to the DSM authors, I'd ask them to look at the history of grieving rituals around the world and througout history and evaluate whether all those people who have ever lost a loved one and who wore black or floated candles down a river or held drunken Irish wake really needed to be on anti-depressants.
I could almost say that it's not the grief that breeds depression, but the isolation-- the lack of ritual and community, the lack of ongoing support and structures for making sense of the loss --that breeds depression. By classifying grief as a mental disorder, I'm afraid they are only compounding this problem.
Yep. I tried to make an appointment. Insurance wouldn't cover my chosen therapist...I gave up. I PROBABLY would have done better if I had followed through, but I just couldn't do it.
I don't particularly care about the label. What I fear is that the label automatically generates a pharmaceutical prescription. Not all depression requires medication. And, being generally disillusioned with the entire medical field, I suspect this is monetarily motivated...as a way to push more pills.
The footnotes and classifications are hard. For me - I've had clinical depression in the past, and refused to medicate, because I didn't think I needed it. And I don't think I did then.
After Gabe though - I don't know if I was depressed or grieving. A distinction wouldn't have mattered, really, in the end for me. I tried to cope on my own and managed for a bit, but not very well, and then it was too much. I wasn't numb anymore, and I was very anxious and very overwhelmed and it had a very physical cast that I had not experienced before. It was when I was at work, trying so hard to concentrate and completely unable to understand a sentence I'd read five times that I realized I needed more help.
The meds helped tremendously. It wasn't a situation for me where it numbed me or made me artificially happy; it was simply that I was able to function again and by functioning again, I was able to deal more effectively with the grief.
It's a double edged sword - by classifying grief as a form of depression, it can make more resources available to those people who might not otherwise have access to them (through insurance, through work place w/ FMLA issues, making prescriptions available, etc). But as you've pointed out - two weeks?! I wasn't near functioning in any meaningful way at 2 weeks.
And there is the risk that it further stigmatizes depression and grieving.
Also the isolation thing is true. Society likes to not hear about your grief after a few months. That's part of why therapy is useful. If I could talk more openly about my grief perhaps I wouldn't still be going to therapy.
Insurance wouldn't cover the therapist that had most worked with grief in my area as. However the therapist I called first took my insurance information and called around for me until she got a list of people she recommended who took my insurance. Very kind of her.
I distinguish grief from depression in many ways, and they are not caused for me by the same things at all. I grieved when we lost our first son. Weeks later, i came down with a random, disgusting illness that made me feel like i couldn't trust my body to do anything at all- and that's when the grief turned into depression. Months later, I was laughing again, I was interested in things again, I wanted things for my life again. But, yup, still grieving. When we lost son #2, grief and depression went hand in hand- but again, the depression lifted and the grief didn't. I know I am depressed when I don't care about much of anything, lose curiosity about things that usually interest me, can't concentrate... I am grieving when I miss my babies.
I saw Frances speak recently- he seemed to me like the voice of decency in a very clinical crowd. I agree with everything he has to say. That said, my own therapist, aware that insurance companies will pay for unlimited sessions if you're being treated for a biologically-based disorder, bills for our sessions under PTSD. If I were treating someone in similar circumstances, i would likely do the same. The system is very, very broken- and, ironically, the diagnosis that gets babyloss wrong is the one that insurance companies get right.
From here it sounds like a safe way to label and contain a very scary emotional place. Baby loss is such a dark, dark experience. We know it as parents, but as Tash says, "babyloss is it's own little dark corner of bereavement." It is a place too awful to contemplate. Everyone has to face the fragility of life when they hear word of a dead baby - and who wants to do that if you can avoid it?
If there is a way to describe 'grief' that makes it about some kind of mental disorder rather than a fundamental life experience, it kind of contains it, makes it safe for everyone else. They don't have to look at those emotions because they are not normal. They are part of some abnormal chemical condition and, by extension then, can be treated with chemicals. We don't have a choice, whether we avail of chemicals or not during our grieving process, we cannot avoid the overwhelming emotions of our loss. Classifying grief as depression does make it easier for professionals (and society) to keep a safer emotional distance from this place of loss.
Semantics do play a part. There are no words. (http://radarofchance.wordpress.com/2010/03/08/there-are-no-words/)
Hah. Now there is no grief either - it is a depression. If there is one thing I am learning as I feel my way along (and I use the word feel here in both the 'no idea where I am going' and the emotional sense), it is that life is not just the good feelings. I would take my daughter back with no hesitation rather than be in this place, but this place is real. This place is life. It is not a mental disorder.
Thank you. I didn't know. I do however know the difference between the groups, and it certainly throws Catherine's comment into new light knowing that those who prescribe and research are doing the writing.
Sorry, Tash.
And the Freddie - beautiful, cared for birth - and a dead baby. And not a hint of depression. I can't work it out. I'm incredibly sad, desperately, heartbroken, but not depressed.
I can't work it out.
I keep being offered counselling and pills and goodness knows what else and none of it seems to have been remotely needed. I think as a society we are very keen to hurl medical help at things now, to assume it fixes anything. It seems to me that grief MIGHT be augmented by depression but if it isn't, medicines are not going to help. This grief is the first time I have ever been able to manage the enormity of the experience. I don't get that at all.
Where depression gripped me and disabled me, shaking me by the throat till I was helpless, grief for my baby boy simply appears to be a process, one I prefer to engage in. Of course, that could all alter in a day - I could be on pills in a week I guess.
None of my depressions have ever been serious (bar one actually) but I've always sort help, got pills, functioned well, none of the kids have been affected. So it came as a hell of a shock to see "mother has history of mental illness" written on the front of Freddie's notes.
The last time (the serious time) I was depressed was loss, hurt, anger and guilt all compounded into one terrible thing. That was complicated, I wish I could have had real help for that loss, which was also for a baby. It makes sheer, acknowledged terrible grief seem almost simple. I suppose we are a sum of our parts.
For me, depression is such a faceted thing - chemicals, experience, support available and the sheer luck of whether you can manage to haul yourself out of it on a particular day when it happens to hit. If you are lucky you can, if all those things conspire against you, you are frankly helpless and need all the help you can get.
I cried all over Freddie for his 11 days of life - but I'd have been furious if someone had worried I was "getting depressed". Likewise, if i went to my doctor now and said "I need help", I'd be furious if he said I was "just grieving".
I didn't really answer the question, did I? :)
It would worry me greatly were grief to be reduced to a simple subset of depression. It also concerns me that the people who would classify it as such may have a vested interest in pathologizing such a central part of what it means to be human or, indeed, alive (as Frances has noted in his article, animals would appear to grieve too).
I was pulled aside by a nurse in the NICU, about two weeks tops after my daughter died, and told to seek help as I 'obviously' had PPD. Mainly on the basis of my slumped posture and occasional tears. In a haze I saw a doctor, was diagnosed with depression and prescribed Zoloft and, as a late addition, mirtazapine. I've taken medication ever since and I have wondered if it has interfered with the grieving process in any way, perhaps I have not 'accrued the benefits' I might have done if my grief had taken its natural course? I'll never know. I was not in a position to think the decision through in the immediate aftermath of my daughter's death and by the time I'd contemplated whether I should be popping these pills or not, it was too late. Maybe I'm one of that group who forever remain on medication which is not necessary?
I agree with the point you've raised in your post and that many have mentioned in comments above, this truly is a 'dark little corner of bereavement.' Like many uncomfortable or frightening experiences it is simply ignored (or so it feels) by society at large. Perhaps if there had been some sort of ritual, some kind of recognition of my grief or even just the simple abiding you describe, it would not have taken on the malignant quality I sometimes fancy it possesses?
As it is my dead daughter has a strange kind of semi existence on the internet and I have some pills. I don't know where I feel the line should be drawn but surely there has to be something preferable to this? Maybe?
Niobe, I know you're not reading this comment but now I'm curious as hell as to some of those conversations.
Not to mention those who try valiantly after losing a baby, to have another and are unable to do so. Depressed. Doesn't cover it.
Grieving a child is so incredibly different and grieving a baby, particularly a stillborn one, unique in its own way. The whole process of going through labor and delivering a dead baby is not something that can ever be understood except by those who have actually done it. Having your body be an active participant in the delivery of your dead child is one of life's cruelest tortures. Just as I imagine having to hold your baby in your arms while they slip away from you must be.
My point is, that our grief is unlike the grief that comes from a death that has followed the natural order of things, or even that which follows a sudden and traumatic untimely death. I think the difference needs to be recognized and acknowledged when trying to wrap a generic diagnosis around any individual"s treatment. My initial thoughts were as I started this para, as in, DUH and Obviously, anyone who has suffered through this also likely dealt with depression. And perhaps the professional would be wise to consider that one is entitled to be depressed after such a loss. The issue then becomes, when has it got to the point where medical intervention is required?
For me, the bottom line would always rest with the individual and their docs. When my friends suggested after a few weeks that I look into anti-depressants, my response was, my baby died, I don't want to medicate the feelings away, they will be waiting for me when I get off the sauce, or I will have to stay on it forever if I don't deal with them now. And for whatever reason, I was able to navigate my way through without more than a few scrips for xanax. But what surprised me, was that years later, after the next baby, after the immediacy, then I again started to feel the 'bad' stuff again. As though I couldn't get past them. And once again, I am considering intervention.
Which brings me back to the different beast of grief that baby loss parents live with and the special care that should be taken when trying to lump them into a generic category.
I think grief, is grief. It is awful, altering, suffocating. Each person needs to grieve their own way and should not be forced to meet plain wrap criteria when being diagnosed.
Bottom line for me, is that anytime you are dealing with mental health issues, all factors need to be considered, not just the circumstances, but the individual. We are all capable of different things, for better or for worse, and what might throw one of us into a pit of despair, another may be able to walk away from without looking back.
I know for me, finding the online support, was a true turning point. I don't know that xanax would have been enough without this place. Knowing you are not alone, that you are not a freak, that others understand, that is HUGE.
Grief=Depression...may be too easy. Depression as a part of the grief process, absolutely.
Apologies again- didn't mean to be obnoxious or imply that you chose the wrong words in your post. I just worry sometimes that mental health treatment is such a secretive thing, and so many of the babylost might be seeking it for the first time, that I err on the side of spelling too much out sometimes.
Another factor in all this for me, though it doesn't apply to everyone- there have been times in my grief and depression when i have needed and desperately wanted to go on medication. One of the things that stopped me is that having an official diagnosis of depression and using insurance benefits to pay for antidepressant medication might, in some cases, complicate our prospects for adoption if it turns out that we really can't conceive and carry to term on our own. Some countries won't look at you at all if you carry a diagnosis or take meds. I was advised by some people in the know to buy medication through an international mail-order pharmacy so it didn't show up in my medical records, and that pretty much killed the whole thing for me.
We know that people who suffer from infertility have rates of depression as high as those who suffer from cancer. And we know that babyloss is its own special hell. But apparently, having both babyloss and infertility, and seeking treatment for them, may reduce your chances of being seen as fit to have a family at all. In this case, bereavement would be a kinder, gentler diagnosis. I know this is a special case and somewhat off topic- but in our case, it's a damned if you do, damned if you don't situation: getting the help i would benefit from to be able to get through the adoption process might blow our chances of adopting from some places all together. Sigh...
OK- off the soapbox now.
I was diagnosed with depression 10 years ago. Months later I decided to go on anti-depressant medication and I have been on them ever since. My depression is a biological thing, a chemical misfire, something "wrong" in my head. It needed the outside help of the medication to set things right and I'm a perfectly functional person (haha). I still need help with my thought processes sometimes, I still sometimes overreact, I'm still very emotional, but I'm no longer paralyzed by the crazy thoughts that I used to be.
The grief of the loss of my son had a very profound effect on my life, in many ways much more severe than the chemical depression I've been battling for years prior. But at the same time the grief was a process, it was a normal reaction to a horrible thing that happened to me, and it felt utterly different. I didn't have to adjust my medication at all, though I did start seeing a therapist to help me work through the grief and after-effects.
So to me I guess the crux of the matter is that neither option satisfies me. Other people don't necessarily experience it so cut-and-dry as I did. Grief certainly cannot and should not be dismissed entirely, it is severe and needs treatment and help. But it's not the same thing as depression, either. They overlap. They have very similar appearances to the observer. But they come from different causes and that I think is an important distinction that should not be forgotten.
I'm grieving normally (I feel) for Freddie. If I weren't, I think it would be manifesting itself in different emotions: guilt, anger, rage to name a few. Those are the things that turn normal into abnormal for me - the things that set my chemicals out of balance. I think depression will come for me if I fail to conceive again, if I cannot control any of my destiny. But I think to categorise grief, now, at this point in my process, would be to diminish the love I have for him.
But I sat that only because I know myself depressed - I'm a thing without reason - and right now I have reason to be sad.
I can't figure out if I need help this time around. This post made me write a post I have been thinking about for some time now.
http://brokenheartdiaries.blogspot.com/
In my experience, the difference between depression and grief/sorrow/sadness is this: both are painful, but at least there is something about the latter that feels alive and vivid.
When first dealing with the loss of Gus and Zoey, I saw a thin boundary between deep sorrow and depression, and I tried to stay on the sorrow-side as much as I could.
My worry is that there are quite a few professionals out there who aren't really qualified to help people through grief, and some of us will fall under their care. I don't know if the footnote helps in these situations or not, but grieving a child can take years (years, plural). It scares me that someone might think that, if a parent isn't "over it" in a few more weeks, something is wrong based mainly on that time scale. And it makes me sad to think that grieving parents might feel pressured, by people who should know better, to heal faster. This pressure shows up too much as is.
http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2010/09/08/a_mothers_grief__without_time_limits/
It seems obvious to me that I'm depressed. My baby died.
It seems obvious to me that I have a damn good reason to be depressed.
I might be depressed or have post partem depression, or maybe I have PTSD. The real question is, do I need meds and a shrink? And related to this post, does said shrink need to a reminder to consider my circumstances when he diagnoses me and determines appropriate treatment?
I definitely have PPD, according to my doc. So she's sending me to a shrink, for appropriate treatment. After reading this and other articles and studies, I'm not sure I'll trust his opinion.
Here's my humble opinion: Circumstances alter cases. I think the footnote should be written into the definition, not be made a footnote or excluded. Someone who is suicidal after loosing a baby or some other loss is obviously severely depressed...and severely bereaved... either way they need help. Obviously, baby loss can become PPD or PP psychosis; widows and other grievers should also have access to some form of modified depression diagnosis. I would hate to see them go untreated. But, damn them if they want to diagnose as depressed and treat someone who is suffering the effects of a loss in the same way as someone who is depressed without an acute loss in their life.
I don't want to be medicated, and I'm not suicidal, I just need to process what happened. I read somewhere recently that ADs are actually as effective as therapy in most cases. I interpret that as a sad commentary on the our society. People are miserable, and 1 hour a week with someone to talk to about it is all they need...that's a disorder?! A disorder of society if you ask me.
Don't even get my started on the insurance implications.
From what I've been reading, it sounds like the shrinks should do some solid research, before they can determine what appropriate treatment means for the bereaved. If at this stage of the game they haven't figured out how to differentiate depression and grief, then I for one will definitely be second guessing their relevance.
If I have PTSD, a prerequisite is that I experienced some mortally terrifying experience: check. Obviously, if someone exhibits the rest of the symptoms, they are going to have to be diagnosed as psychotic or in another way. But if I'm temporarily depressed due to an emotionally painful experience, I think therapy is what I need, and I bet most bereaved folks would benefit from therapy, with the occasional one needing more aggressive treatment. Regardless of if a person just experienced a life-altering loss or not, if they are severely depressed or suicidal they need treatment. The problem is, if they can't determine the difference between the trajectory of bereavement depression and a more generalized form of depression, and they don't have a definition that tells them to, how can I trust them to medicate me or treat me appropriately?
I am coming to terms with what happened to us, but it has taken over 3 months so far, and I still have farther to go. I can accept that. I lost my father a number of years ago, and it took me 3 years to be able to talk about him without tears. That's just the way it is. I hate that while women like me are sent to the shrink (I still haven't gotten in by the way, it's a 6 week wait on the "urgent" list), there are homeless people and others with real, chemical, clinical problems that are going untreated.
I think that's enough for now. This is not the place for more ranting off topic, I am just hoping that if this change is made, it will not result in women being erroneously treated long-term for an 'illness' that is natural. The way I see it, treating depression and grief is like medicalizing pregnancy. Sometimes the doctor is only needed there as a coach to reassure and talk her through it, sometimes they're needed, and other times, there's nothing they can do. In all cases, the talking is the part we remember.